STATEMENT OF ACCOUNT

CHART NO . PAGE NO .
99561 1
Pacific Medical Centers
206.621.4466, 9am-5pm PST BILLINGDATE
1200 12th Avenue S 07/07/23
Seattle, WA 98144
Credit Card # EXP
NaME AS IT APPEARS ON THE CARD
GUARANTOR MAILING ADDRESS
Byron Claflin SIGNATURE
2002 S Inland Empire Way TRLR 12
TYPE OF CARD AMOUNT ENCLOSED
Spokane, WA, 99207
509-655-1704 $

TO INSURE PROPER CREDIT PLEASE DETACH THIS PORTION OF THE STATEMENT WITH YOUR PAYMENT

PLEASE RETAIN THIS PORTION FOR YOUR RECORDS

DATE DESCRIPTION PATIENT CHARGES CREDIT

07/07/23-07/10/23 Laboratory Services Claflin,Byron 1,638.00
07/07/23-07/10/23 Pharmacy 22,644.80
07/07/23-07/10/23 Supplies 10,825.00
07/07/23-07/10/23 EKG Services 4,597.36
07/07/23-07/10/23 Emergency Room 18,110.00
07/07/23-07/10/23 Respiratory Therapy 5,776.54
07/07/23-07/10/23 Room & Nursing Care 19,219.00
07/07/23-07/10/23 Pathology Services 344.00
07/07/23-07/10/23 Surgery 25,208.67
07/07/23-07/10/23 Recovery 4,875.00
07/07/23-07/10/23 Physical Medicine & Rehab 2,832.00
07/07/23-07/10/23 Diagnostic/Therapeutic Services 33,719.00
07/09/23 WELLCARE WA PAYMENT -97,236.59
07/10/23 WELLCARE WA PAYMENT -51,050.08
07/10/23 ONLINE PORTAL PAYMENT -1,425.70

Your insurance has been charged the remaining balance is your responsibility .

CURRENT BALANCE OVER 30 DAYS OVER 60 DAYS OVER 90 DAYS TOTAL BALANCE INSURANCE EST..

$77.00 $0.00 $0.00 $0.00 $77.00

i $0.00

DUE 08/15/23 MAKE EASY PAYMENTS ONLINE @ www.pay.keypatient.com/Form/Payments/New PLEASE PAY

THIS AMOUNT
.. I $77.00
I